Late last year, Bryan Monnin spent 40 days in the Spokane County Jail begging nurses to do something about his broken elbow.
It was a substantial injury that clearly required a cast or surgery, according to several medical professionals who have reviewed Monnin’s X-rays.
“NEED to see doctor,” Monnin wrote in a treatment request in October. “I have badly broken elbow and am in severe pain.”
Yet the jail’s medical staff acted slowly, even as Monnin repeatedly told nurses the pain was excruciating. His case highlights concerns about treatment delays at the county jail, which has a constitutional duty to provide adequate medical care to inmates. It also raises questions about a private company that the county hired to administer that care.
Monnin, 25, doesn’t dispute how he got the injury. It was Oct. 21, and he tried to outrun a Spokane police officer who had spotted him driving a stolen pickup truck in a neighborhood near the NorthTown Mall. The officer ended the chase by tackling Monnin from behind, and his elbow cracked when he landed on the sidewalk.
After his arrest, he was taken by ambulance to Deaconess North Hospital, sick from heroin withdrawal and the pain in his elbow beginning to set in. X-rays made clear the extent of the damage. A doctor prescribed him oxycodone and referred him to an orthopedic surgeon.
Monnin was booked into jail the same evening. It already had been a day since his last fix of heroin, and he was experiencing severe withdrawal symptoms. Jail nurses didn’t want to feed his addiction with opioid painkillers, so he got ibuprofen instead.
With his arm wrapped in a cloth bandage, Monnin repeatedly asked to be sent to a surgeon, verbally and in writing. But jail nurses claimed it took weeks to obtain and review his medical records from Deaconess and said he couldn’t see a surgeon until that process was completed.
And, because they are employed by a private contractor, NaphCare Inc., the nurses told Monnin that any visits to an outside physician would require approval from the company’s headquarters in Birmingham, Alabama.
Monnin saw the jail’s in-house doctor on Nov. 15, more than three weeks after he was booked. Dr. Jeff Maple, a NaphCare employee, observed: “Confirmed by X-ray. Needs to see ortho asap. … Has pain in it but hasn’t had pain meds. Not really asking for much other than needs to see ortho.”
Jail staff finally brought Monnin to a surgery consultation on Nov. 23, a week before the end of his sentence. Surgery was scheduled for Nov. 30, the day he was released, but Monnin said no one informed him about the appointment.
After he was out, it didn’t take Monnin long to schedule another consultation, and he underwent surgery on Dec. 8.
Dr. Soren Olson, who performed that surgery, said the injury should have been obvious to anyone who looked at the X-rays.
In separate interviews with The Spokesman-Review, Monnin and other former inmates described similar experiences with the jail’s medical care provider, NaphCare.
Jail officials say the quality of care has improved dramatically since NaphCare was hired in May to address a shortage of nurses at the jail. Former jail nurses, however, say the company’s strict protocols and cost-saving measures force some prisoners to languish.
Tod Fleming, the physician assistant who saw Monnin at the Nov. 23 consultation, said the elbow fracture should have been treated with more urgency.
“This isn’t something you should sit on,” Fleming said. “He should have been taken in right away.”
NaphCare, he added, “really did drop the ball on this one.”
Former jail nurses decry privatization
For many years, there weren’t enough nurses to treat the hundreds of inmates in Spokane County’s custody. Because of the shortage, nurses often worked long hours, and there was usually no one to screen arrestees as they arrived in the booking area.
County officials tried to recruit additional nurses, but they said it was difficult to offer competitive salaries and lure skilled applicants away from jobs at local hospitals. In early 2016, three nurses resigned over the course of several weeks. By April, total medical staffing regularly dipped below half of authorized levels.
Dr. Criswell Kennedy, who served as the jail’s medical director, wrote to jail officials in an April 8 email that “if we have to struggle through months of transition on a skeleton staff, every terrible medical problem and complication imaginable will occur.”
The county already was facing several lawsuits over deficiencies in the jail’s medical care. Kennedy urged county officials to bring in NaphCare, which specializes in correctional health care and operates in more than 50 facilities across the country.
Spokane County officials visited several sites where NaphCare already provided medical services, including the county jails in Tacoma and Las Vegas. In May, county commissioners awarded the company a six-month, $2.6 million contract, which was extended in October.
“We didn’t really have any other choice,” said John McGrath, the director of Spokane County’s detention services. “Whether I personally agreed with going to a contractor or not, I came to a conclusion that we had no choice at that point.”
NaphCare implemented its own records system and assumed administrative control over the jail’s medical operations, but the company wasn’t supposed to replace any nurses on the county’s payroll. The contract stipulated that NaphCare and the county nurses each would fill about 13 full-time positions at the jail and the Geiger Corrections Center. Public and private employees would do the same jobs side by side.
That arrangement caused problems from the start. Nurses who had worked at the jail for years said they were caught off guard when NaphCare dismantled the old system, throwing out supplies and reorganizing offices without explanation.
Kerrie Fernlund, who was vice president of the county nurses union, described the company’s arrival in May as “a complete hostile takeover.”
Attempts to interview NaphCare employees were unsuccessful. One employee said he couldn’t comment without corporate approval.
Brad Cain, a spokesman and attorney for NaphCare, did not grant interviews with any employees in Spokane or at the company’s headquarters in Birmingham. He responded to inquiries by email.
“NaphCare routinely works hand-in-hand with medical staff utilized by the County to carry out its contractual obligations within a facility,” Cain wrote. “Our main goal is to ensure our patient populations receive quality and efficient care and we strive to work with all parties to meet this goal.”
County nurses said NaphCare employees refused to hear their concerns, and they worried about losing their medical licenses over mistakes that the company was responsible for.
Fernlund said the company’s protocols were so time-consuming that some inmates languished for weeks after submitting treatment request forms, commonly known as “kites.”
“You’d get a kite for a toothache; by the time you go triage it, it’s a full-blown abscess,” Fernlund said.
County nurses also claimed that NaphCare pressured them to resign.
“A lot of people got in trouble for questioning NaphCare decisions,” said Steve Moore, who was president of the county nurses’ union.
Barb Weston, another former county nurse who briefly worked on NaphCare’s payroll, said the jail became “a place where if you say the wrong thing, you’re screwed.”
Allegations flew until the last of the county nurses resigned in October. In settlements with the county, nine nurses each received $18,500, and Moore received $20,000 after contesting an investigation into his nursing practices.
Steve Bartel, the county’s risk manager, said that investigation would not be made public because no allegations were finalized. The settlement, he said, enabled Moore and the county to “part ways” without further dispute.
Moore has been a registered nurse in Washington since 1993 and has no disciplinary history with the state Department of Health.
Most, if not all, of the county nurses have found new jobs; three continued working at the jail on NaphCare’s payroll. Dr. Kennedy retired, and Dr. Gilbert Escandon, who also served as a medical director, went on to perform the same duties at the county’s juvenile detention center.
Their departures left NaphCare as the sole provider of medical care for jail inmates. Although it was a bitter transition, McGrath, the detention services director, said the jail’s medical unit is fully staffed for the first time in years.
NaphCare installed a nurse in the booking area to screen arrestees as they arrive at the jail. That means inmates can be sent to the jail’s medical ward or to a local hospital before they see the inside of a cell.
The company also has a detailed protocol for monitoring drug addicts suffering from withdrawal, and jail officials say the corporate structure adds a layer of quality assurance.
“I can’t stress this enough,” McGrath said. “Things are better now than they were before.”
Inmates allege slow medical response
Mary Ann Monnin contacted The Spokesman-Review in early November, about two weeks after her son was arrested. She lives in Texas and had been talking to Bryan by phone while he was in the Spokane County Jail. She made no excuses for his criminal behavior. She was just worried about his elbow.
“I agree that if you do the crime, you do the time,” she said. “I also believe that we’re a humane society, and that everyone should be treated with compassion when they have an illness or injury.”
Bryan Monnin got hooked on prescription painkillers after a knee surgery in the eighth grade and was shooting up heroin by the end of high school, his mother said. Since then, he’s been jailed about half a dozen times, mostly for misdemeanor drug charges. He’s back there now, in fact, after failing to check in with his parole officer.
“His biggest crime is he’s an addict,” Mary Ann Monnin said. “He really wants to get his act together, and if he could get into some kind of long-term treatment, I really believe he could get his life cleaned up.”
Monnin authorized NaphCare to release his medical records to The Spokesman-Review and authorized jail officials to discuss them. Cain, the NaphCare lawyer, did not respond to inquiries about Monnin’s treatment.
Monnin arrived at the jail on a Friday with a slip from Deaconess stating that his elbow was broken and that he should follow up with an orthopedic surgeon the following Monday.
NaphCare “definitely knew he was injured,” said Sgt. Tom Hill, who oversees the jail’s medical operations. “I don’t know that they knew the severity of the injury.”
In recent years, local officials have made a concerted effort to improve living conditions in the county’s overcrowded detention facilities.
They’re working to reduce the inmate population with funding from the MacArthur Foundation. They commissioned a report from the National Institute of Corrections and acted quickly on the institute’s recommendations. They collaborate through the Spokane Regional Law and Justice Council.
Among recent accomplishments, jail and health district officials won approval to administer methadone – a drug that quells the physical symptoms of opioid withdrawal – to inmates.
Hill didn’t know all the details of Monnin’s case but said he’s confident the reform efforts are paying off. Mistakes are being caught, and NaphCare procedures are being adjusted to meet the specific needs of Spokane County’s facilities.
“What I can say with absolute confidence is that we’re getting better, and better, and better,” Hill said.
Yet he acknowledged that some problems can still be overlooked.
Another former inmate, Patricia Swiger, claims she was denied medications for weeks because the jail’s medical staff was slow to obtain prescriptions from her doctor.
She was jailed last summer for violating her probation after shoplifting at the Target store in north Spokane. At the time, the medical staff still included some county nurses under NaphCare’s supervision.
Swiger, 50, has a gastrointestinal disease that causes constipation. Without medication, she said, her stomach became so bloated that she looked “nine months pregnant” on several occasions.
Attempts to obtain Swiger’s medical records were unsuccessful. But Ray McClusky, a close friend of Swiger’s, said he called the jail to voice concerns about her treatment, and she eventually received some, but not all, of the medications prescribed to her.
Another inmate, Kurt Warren, claims nurses ignored a MRSA infection, a staph infection resistant to many antibiotics, that spread across his face while he was jailed on an assault charge last summer.
“I told them that something was wrong with my nose, and they just didn’t do anything about it,” Warren said. “They all knew there was something wrong with me. They just kept saying, ‘We’re going to let the provider know.’ ”
Warren, 54, said he was given no antibiotics for nearly two weeks after he first reported the infection. As it festered, he said, he started bringing a towel to cover his face while eating in the jail cafeteria. He said he was finally taken to Providence Sacred Heart Medical Center in early August.
“My eye was swollen shut, and my lip actually split open with pus,” he said. “They did a CT scan on my head and immediately put me into surgery.”
Warren said he underwent several surgeries during a 16-day stay at Providence before he was returned to the jail. He filed a federal lawsuit against NaphCare in October, but no hearings have been scheduled.
“They just need to be held accountable,” he said, “so this doesn’t happen to somebody else.”
Nurses question NaphCare priorities
In Spokane County, NaphCare is contractually obligated to pay for inmates’ medications and many off-site services, such as hospital visits and ambulance runs, up to $15,000 per inmate. The contract gives NaphCare broad latitude to decide what’s “medically necessary” for a given inmate.
Former county nurses accused the company of cutting costs with little regard for patient care.
Several nurses said, for example, that NaphCare’s corporate office routinely canceled their orders for a long-acting form of insulin and replaced them with a cheaper alternative. Kennedy, the former medical director, leveled the same charge in July and said some diabetic inmates suffered as a result.
Dr. Maple has served as NaphCare’s medical director at the jail for about four months. Despite his presence, the company requires that prescription orders and other treatment recommendations be logged into an electronic system and approved by the Birmingham office.
That process enables the company to catch mistakes and ensure quality of care, according to Cain, the NaphCare lawyer. He wrote in an email that the Birmingham office is staffed with doctors and health care providers in various specialties.
“Orders are not canceled without discussion with the ordering provider, and alternate plans of care are discussed and provided,” he wrote.
Cain also said the company adheres to standards laid out by the National Commission on Correctional Health Care. “The costs of medications,” he wrote, “do not factor into medicating decisions.”
McGrath, the detention services director, said the county plans to hire an independent doctor to conduct periodic audits of the jail’s medical care. A similar measure is already in place for mental health care, he said.
County officials also recently accepted preliminary bids from other correctional health care contractors. As they consider whether to replace NaphCare, they are seeking advice from Dr. Marc Stern, a correctional health care expert at the University of Washington who once served as the state prison system’s top doctor.
“I don’t think, in and of itself, that having private companies in health care is a problem,” Stern said. “The problem is that correctional health care is underfunded to begin with.”
But future contracts may need “a little more verbiage” defining the medical provider’s obligations, he said.
“I think it’s really helpful to have a definition of what’s medically necessary.”